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Running head: A COGNITIVE BEHAVIORAL APPROACH 1

A Cognitive Behavioral Approach To Family Counseling

Kimberly A. Osburn

Liberty University Online

October 14, 2011


A COGNITIVE BEHAVIORAL APPROACH 2

Abstract

Goldenberg and Goldenberg describe several empirically validated theoretical approaches to

family therapy. Cognitive behavioral therapy (CBT) is one such approach, with abundant

research supporting its efficacy for couples in conflict. Research has demonstrated the efficacy of

Cognitive-Behavioral Family Therapy (CBFT) in treating youth with mood and anxiety

disorders, showing a high rate of sustained long-term success in the treatment of pediatric

obsessive-compulsive disorder. Although critics denigrate the cognitive-behavioral approach for

its tendency to employ a Eurocentric view, CBFT is flexible enough to accommodate clients of

various cultural backgrounds, particularly in cultures where family cohesiveness and

interdependence are highly valued, such as African American, Middle Eastern, and East Indian

cultures. CBFT also integrates effectively with other theoretical approaches for those counselors

who favor using an eclectic approach in family therapy. Principles and techniques of CBFT are

easily integrated with Scriptural principles applicable to Christian counseling.


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A cognitive behavioral approach to family counseling

Part I

Goldenberg and Goldenberg (2008) describe several empirically validated theoretical

approaches to family therapy. Cognitive behavioral therapy (CBT) is one such approach, with

abundant research supporting its efficacy for couples in conflict (Dattilio and Epstein, 2005).

Research has demonstrated the efficacy of Cognitive-Behavioral Family Therapy (CBFT) in

treating youth with mood and anxiety disorders (Katz, Fotti, & Postl, 2009), showing a high rate

of sustained long-term success in the treatment of pediatric obsessive-compulsive disorder

(McHugh O'Leary, Barrett, & Fjermestad, 2009). Although critics denigrate the cognitive-

behavioral approach for adopting a Eurocentric view in research and practice (LaTaillade,

2006, p. 347), CBFT is flexible enough to accommodate clients of various cultural backgrounds,

particularly in cultures where family cohesiveness and interdependence are highly valued, such

as African American (LaTaillade), Middle Eastern (Khodayarifard, Rehm, & Khodayarifard,

2007), and East Indian cultures (Dattillio & Bahadur, 2005). A culturally sensitive application of

CBFT techniques allows for the modification of schemas in a way that is respectful to cultural

underpinnings and allows the family the freedom to change in a manner that does not

compromise their cultural values (Dattillio & Bahadur, p. 367). CBFT also integrates

effectively with other theoretical approaches for those counselors who favor using an eclectic

approach in family therapy.

Liberman and Stuart, early behaviorists working with couples and families, were

primarily concerned with modifying observable behavior between individual family members,

using operant conditioning techniques to reinforce desired behaviors (Goldenberg & Goldenberg,

2008). As behaviorists began to take a more eclectic approach in the late 1970s, the influence of
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internal cognitions on external behavior was recognized (Goldenberg & Goldenberg). As efforts

evolved to integrate techniques for changing of cognitions with behavior modification

techniques, cognitive-behavioral therapy was born.

Goldenberg & Goldenberg (2008) credit Albert Ellis and Aaron Beck as being the first

therapists to address cognitions in the resolution of conflict between couples. Ellis, the

grandfather of cognitive behavior therapy (Corey, 2005, p. 269), was influenced by Adler, who

believed that our emotional reactions and lifestyle are affected by our cognitive beliefs (Corey).

According to Dattilio and Epstein (2005), Ellis theorized a linear causality of relationship

conflict rooted in a person having irrational or unrealistic beliefs about his or her partner and

relationship (p. 7). The failure of ones partner to live up to these unrealistic expectations leads

the individual to draw extreme negative conclusions about the partner and relationship, stirring

up extreme negative emotions and leading to negative behavior towards the partner. This resulted

in the development of Elliss A-B-C Theory (Goldenberg & Goldenberg, p. 312), in which it

is not the activating events (A) of peoples lives that have disturbing consequences (C), but the

unrealistic interpretation they give to the events, or the irrational beliefs (B) about what has taken

place that cause them trouble (p. 312). Ellis addressed this theorized cause of relational conflict

by developing Rational Emotive Therapy (RET), later renamed Rational Emotive Behavior

Therapy (REBT), a method of identifying irrational cognitions, restructuring them to develop

more rational, realistic, and constructive beliefs (Goldenberg & Goldenberg).

Petersen, Sweeten, and Geverdt (1990) offer the following example of an A-B-C

analysis: Joe is walking along a path, and sees a snake. Joe panics and runs away. The activating

event (A) is Joes encounter with the snake, and the consequential feeling and behavior (C) was

that Joe panicked and ran away. However, it would not be correct for Joe to say, The snake
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scared me. The snake was simply present on the path, and did not take an active role in scaring

Joe. What caused Joe to panic and flee was his underlying belief (B) that snakes are dangerous.

This arguably might not be an irrational belief, depending on the type of snake Joe

encountered on the path. Nonetheless, Joes underlying belief created an unpleasant state of

anxiety, interrupting his trip down the path. Employing an REBT approach, Joe might consider

altering his underlying belief statement Snakes are dangerous to This snake may or may not

be dangerous, but if I do not bother it, it will not likely bother me. Such a belief might help Joe

have the courage to calmly walk around the snake and continue walking along the path.

Beck combined cognitive behavior theory with a systems perspective, viewing family

interactive patterns as being equal in importance to cognitions (Goldenberg & Goldenberg,

2008). His theory of the role of cognition in dysfunctional behavior is rooted in his work with

persons with depression. Beck theorized that depression resulted from erroneous patterns of

thought. As people internalize negative attributions regarding difficult life experiences, they

develop negative schemas (enduring sets of core beliefs and attitudes about people,

relationships, and so on, that organize subsequent thoughts and perceptions) (Goldenberg &

Goldenberg, p. 313). Each time a new situation occurs that resembles the initial situation in

which the schema was formed, the schema and its accompanying negative emotions are

reactivated. This process leads to the development of cognitive distortions, altering the depressed

persons perception of reality (Goldenberg & Goldenberg, p. 313).

Although there are many ways of defining cognitive distortions, Ping (2000) identifies

eight common distortions, referred to as Thinking Bugs (pp. 12-16):


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1. Should: Thoughts of shame based on expectations of what should or should not be,

distracting the person from focusing on what actually is and moving towards problem

resolution.

2. Past: Focusing on past events and what could have been if only things had happened

differently, rather than accepting the reality of what happened and moving forward.

This focus is tied closely together with unforgiveness of the self and others for past

offenses.

3. Future: Ruminating over worries and fears about the future (what if thoughts) over

which the person has no control. Such thoughts drain the persons energy, preventing

them from focusing on the here-and-now.

4. Perfection: The unrealistic belief that if something cannot be done perfectly, it is not

worth trying at all, this focus keeps a person trapped in a state of helplessness and

shame.

5. Magnification: Magnification involves what Ellis referred to as catastrophizing

making extreme negative evaluations about a relatively commonplace event (e.g. I

made a mistake; therefore I am completely worthless) (Goldenberg & Goldenberg,

2008, p. 312). Thinking in unrealistic extremes such as always and never, a wife

might say to her husband, You are always yelling at me! Does the husband literally

yell at his wife nonstop from the moment he awakens in the morning to the moment

he falls asleep at night? Probably not. Such thought patterns keep the person trapped

in a pattern of blame and negative attributions, preventing them from recognizing

exceptions to the problem that might lead to resolution.


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6. Invalidation: A person may become so entrenched in applying negative attributions

and evaluations to events that even positive occurrences are viewed in a negative light

(e.g. My teacher gave me an A; I got lucky. I didnt deserve it rather than thinking,

My teacher gave me an A; I did a good job!).

7. Mind Reading: Making negative attributions and evaluations about another persons

intent in behavior based on an erroneous belief that one knows what the other person

is thinking.

8. Blame: An unwillingness to take responsibility for ones own behavior,

unrealistically externalizing blame to another person, or to circumstances presumed to

be beyond ones control (e.g. If that redneck cop hadnt been on a power trip, he

wouldnt have given me a speeding ticket, as opposed to I was speeding and got

caught; therefore I got a ticket.).

Beck focused on creating situations for clients that disproved negative schemas and

cognitive distortions (Goldenberg & Goldenberg, 2008). Applied to family therapy, this

approach helps each family member to examine personal schemas regarding expectations of

marriage and family relationships and how such expectations influence individual behavior. The

family is also encouraged to examine collective schemas the family has developed regarding

their interactions. The family can then work together to modify these individual and collective

schemas to remove dysfunctional beliefs, thus bringing about positive behavioral change within

the family (Goldenberg & Goldenberg).

Some of the strongest modern-day proponents of CBFT include Frank Dattilio, Norman

Epstein, and Donald Baucom (Goldenberg & Goldenberg, 2008), whose names appear frequently

in research articles on the effectiveness of CBT techniques in therapy with couples and families
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(Dattilio & Epstein, 2005). Baucom and Epstein identified five cognitive distortions that

commonly affect couples (1990, as cited in Dattilio & Epstein, p. 9):

1. Selective perceptions of relational events

2. Distorted attributions about causes of events

3. Inaccurate expectations or predictions of future events

4. Inaccurate assumptions about the general nature of relationships

5. Unrealistic standards to which the relationship is held

Similar to Becks approach, Baucom and Epstein (1990, as cited in Dattilio & Epstein,

2005) advocate helping couples examine and modify these cognitions, developing healthier

communication patterns for future interactions.

Cognitive-behavioral theory is not the only theory to take internal thought processes into

consideration. Psychodynamic theory relies heavily on the effects of unconscious drives on

external behavior, and the necessity of gaining insight in order to achieve behavioral change.

While CBT focuses primarily on conscious thought, Beck proposed that negative schemas exist

on a level that might be considered subconscious in nature, if not completely unconscious.

Dattilio & Epstein (2005) point out that the use of reframing techniques in both structural and

strategic therapy acknowledge the significance of cognitions in sustaining negative interactional

patterns within a family, although structural and strategic therapists are less concerned with

helping families gain insight, placing greater emphasis on applying therapeutic techniques to

alter behavior (Goldenberg & Goldenberg). The Milan technique of positive connotation is

another reframing technique focused on altering cognitive attributions in attempt to bring about

resolution of symptomatic behavior, while the social constructionist use of narrative therapy

techniques may be seen as an attempt to replace negative cognitions with positive ones
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(Goldenberg & Goldenberg). However, CBFT is the only theoretical perspective that employs

consistent systematic methods to assess and intervene with cognition in intimate

relationships (Dattilio & Epstein, 2005, p. 9).

Part II

As a former consumer of psychotherapy, I found that REBT helped to revolutionize my

way of thinking, bringing about a vast improvement in symptoms of depression and anxiety.

Although I was in individual therapy, my husband attended a session with me in which the

counselor showed us a modified A-B-C technique devised by Petersen et al. (1990). We were

able to apply this technique to modify our cognitions about our relational interactions, thus

strengthening our marriage.

Additionally, as one who aspires to work in the future as a Christian counselor, I find the

principles of CBT to be easily integrated with the teachings of the Bible. Various Scriptures

support the concept that a persons inner thoughts have a profound effect on outward behavior.

Proverbs 23:7 (New American Standard Bible) says of a man, As he thinks within himself, so

he is. Jesus said that it is out of the overflow of the heart that the mouth speaks (Luke 6:45). The

Greek word used for heart in this passage is similar to the word used for mind in other

passages (Petersen et al., 1990). In 1 Samuel 16:7 (New Living Translation), the Lord told

Samuel, People judge by outward appearance, but the LORD looks at the heart, implying that

our inner cognitions take greater precedence over our outward appearance and behavior.

REBT proponents believe human beings are fundamentally imperfect; one of the goals of

REBT is to help people learn to accept themselves and others unconditionally (Corey, 2005).

Gods unconditional love for people despite their imperfections is an overarching theme of the
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Bible: But God demonstrates his own love for us in this: While we were still sinners, Christ

died for us (Romans 5:8, New International Version). At the same time, CBT encourages a

realistic view of the self and others, which is consistent with Romans 12:3 (New Living

Translation): Be honest in your evaluation of yourselves, measuring yourselves by the faith God

has given us.

Another goal of CBT is to alter dysfunctional behavior patterns by changing inner

thought processes. This concept is consistent with Pauls admonition in Romans 12:2 (New

Living Translation): Don't copy the behavior and customs of this world, but let God transform

you into a new person by changing the way you think.

Petersen et al (1990) elaborated on Elliss A-B-C analytical technique to produce a

technique called Rational Self Analysis (RSA), from which the example below is adapted:

A: Activating Event B: Beliefs C: Consequential D: Decisive


My perception of what What underlying beliefs Feelings Behaviors
happened might have affected my How did I feel What did I do in response
perception of what immediately after A to A?
happened, my occurred?
consequential feelings, and
my response?

My husband said I look I look ugly without Hurt, sad Replied by saying Yeah,
nice today because I had makeup. right! sarcastically, then
makeup on. My husband only loves slammed the door.
me when I look nice.

I: Camera Check II: Desired Beliefs III: Desired Feelings IV: Desired
If a video camera had How might I modify my How would I prefer to feel Behaviors
recorded the Activating underlying beliefs to avoid if this event were to How would I prefer to
Event, what would I see? negative feelings and happen again? behave if this event were
(i.e., an objective behaviors if this event to happen again?
perspective check) were to happen again?

My husband smiled at me I am beautiful, inside and Happy, flattered, affirmed, Accept the compliment and
and said, You look nice out. loved say Thank you instead
today honey. He never My husband thinks Im of reacting out of
mentioned noticing that I beautiful. insecurity.
was wearing makeup. My husband loves me
unconditionally.
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The focus on Decisive Behaviors (D) in addition to Elliss traditional A-B-C outline

encourages clients to take responsibility for their actions, which are viewed as chosen rather than

consequential behaviors. The Camera Check (I) allows clients the opportunity to evaluate

whether their personal perspective of what happened is what actually happened a concept

borrowed from the postmodern philosophy that we each construct our own personal view of

reality (Goldenberg & Goldenberg, 2008). The Desired Feelings (III) and Desired Behavior (IV)

sections are an extension of cognitive restructuring, helping clients envision the possibilities of

positive change. This is a similar concept to the restorying techniques employed in narrative

therapy (Goldenberg & Goldenberg).

The aforementioned cognitive distortions outlined by Ping (2000) may be presented to a

client couple or family in a psychoeducational session, then utilized alongside the Rational Self-

Analysis technique to analyze specific conflict situations. Alternatively, the therapist may allow

family members to relate their personal narratives of the familys interactive processes, then

encourage them to reexamine their narrative in light of the list of cognitive distortions, looking

for potential Thinking Bugs (p. 12) in their narratives. For example, the couple described in the

previous RSA example may have experienced several cognitive distortions during the course of

this brief interaction. The wife may hold an underlying belief that Unless I look perfect, my

husband wont love me (Perfectionism). She may fear that her husband will leave her in the

future if she does not maintain a high standard of appearance. Perhaps she has insecurities about

her appearance based on past negative comments her husband has made for which she has not

forgiven him. She believes her husband is only complimenting her appearance because she is

wearing makeup, but that he does not think she is beautiful without makeup (Mind-Reading). By

her sarcastic response, she is invalidating her husbands compliment. The husband may respond
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by thinking, Nothing I say to my wife is ever good enough. She always takes things the wrong

way! (Magnification). The husband may also think his wife shouldnt be so overly sensitive.

CBFT techniques may be employed in analyzing child-parent conflict as well,

particularly with adolescents who tend to make negative attributions of their parents intentions

when conflict arises (e.g. My parents are grounding me this weekend because they hate to see

me have a good time with my friends.) (Goldenberg & Goldenberg, 2008, p. 314). From a faith

perspective, an adolescent can be encouraged to examine core spiritual beliefs, determine how

those beliefs influence current behavior, and consider how they might bring about desired

changes in behavior. Adolescents tend to question authority and search for inconsistencies in

societal rules (Feldman, 2008). Thus providing adolescents with opportunities to question and

reformulate their belief systems may help them to engage more willingly in the therapeutic

process rather than resisting it. However, extreme cultural sensitivity must be exercised at this

point, as the encouragement of such questioning and independent thought may be perceived as

subversive by Christian families who value unquestioning obedience to parents according to

Colossians 3:20 (New International Version): Children, obey your parents in everything, for this

pleases the Lord.

While CBFT can be a useful approach in many circumstances, it is important to

recognize that it requires a level of cognition that might not be present in very young children, or

persons with psychosis whose insight and ability to perceive reality is impaired. However,

research has demonstrated the success of CBFT in families of children and adolescents with

anxiety disorders as compared to other treatment methods (Katz et al., 2009). McHugh O'Leary

et al. (2009) conducted a 7-year post-treatment follow-up study of participants who received

either individual or group CBFT for the treatment of obsessive-compulsive disorder. Participant
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ages ranged from 6-17 years old at the time of treatment. Results showed that around 87 percent

of the sample were diagnosis free 7 years post-treatment (McHugh O'Leary et al., 2009, p. 976).

The idea that CBFT would be effective in reducing anxiety symptoms is consistent with a

Scriptural view of anxiety. In his letter to the Philippians, Paul writes:

Dont worry about anything; instead, pray about everything. Tell God what you need, and

thank him for all he has done. Then you will experience Gods peace, which exceeds

anything we can understand. His peace will guard your hearts and minds as you live in

Christ Jesus. And now, dear brothers and sisters, one final thing. Fix your thoughts on

what is true, and honorable, and right, and pure, and lovely, and admirable. Think about

things that are excellent and worthy of praise. Keep putting into practice all you learned

and received from me everything you heard from me and saw me doing. Then the God

of peace will be with you. (Phil. 4:6-9, New Living Translation)

In this passage, Paul suggests that if one releases anxious thoughts to God through prayer,

and then changes the focus of his or her thoughts to things that are positive, that person will

experience inner peace.

CBFT techniques may be integrated with prayer and Scripture as appropriate, either

implicitly or explicitly (Tan, 2007). Implicitly, the counselor may silently pray for client families

during and between sessions, maintaining a mindfulness of Scriptural principles while doing

CBT exercises with clients to challenge distorted cognitions. Explicitly, the counselor might use

Scripture to confront client beliefs that are contrary to Scripture, and offer to pray with clients for

God to help them change their thought patterns and heal relationships. Extreme caution must be

exercised in such a directive, confrontational approach, due to the inherent power differential

that exists in the therapist-client relationship (American Association for Marriage and Family
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Therapy, 2001, Section 1.3), as well as differences in Scriptural interpretation among different

denominations.
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